RESEARCH AND PRACTICE
A Prospective Study of Clinical Outcomes Related to
Third Molar Removal or Retention
Greg J. Huang, DMD, MSD, MPH, Joana Cunha-Cruz, DDS, MPH, PhD, Marilynn Rothen, RDH, MS, Charles Spiekerman, PhD,
Mark Drangsholt, DDS, PhD, Loren Anderson, DDS, and Gayle A. Roset, DDS
Third molar removal is one of the most
common dental surgical procedures in the
United States, representing 95% of all extrac-
tions among patients aged 16 to 21 years in an
insured population.1 Although the risks associ-
ated with third molar removal are generally
minor, such as pain and swelling, some com-
plications may be more serious, such as injury
to the temporomandibular joint (TMJ) or per-
manent paresthesia. Because many third mo-
lars are surgically removed, the costs associated
with this procedure can be significant. One
report estimated that more than $3 billion is
spent annually in the United States for third
molar removal.2 Because decisions regarding
removal or retention of third molars are often
made in late adolescence and early adulthood,
understanding the risks and benefits of re-
moval or retention during this time period is
important.
The prophylactic removal of asymptomatic
third molars has been the subject of consider-
able controversy. On one hand, some have
advocated early removal of third molars as
beneficial to patients to prevent the risk of
future pathology and to minimize operative
and postoperative risks.3---6 Another common
argument for third molar removal is prevention
of crowding of lower incisors. In the past
decade, prevention of periodontal pathology
has been proposed as a reason to prophylacti-
cally remove third molars.7,8 This theory sug-
gests that periodontal pathology initiates in
third molars and is more likely to proceed
when third molars are retained. Additionally, if
left unaddressed, the periodontal pathology
may lead to negative cardiovascular, obstetric,
metabolic, and renal health outcomes.9
On the other hand, third molar removal can
result in various types of morbidity, such as
pain, swelling, bleeding, infection, dry socket,
trismus, paresthesia, and temporomandibular
joint disorder (TMD).8 Most of these compli-
cations resolve, but some, such as paresthesia
728 | Research and Practice | Peer Reviewed | Huang et al.
Objectives. We investigated outcomes of third molar removal or retention in
adolescents and young adults.
Methods. We recruited patients aged 16 to 22 years from a dental practice–
based research network in the Pacific Northwest from May 2009 through
September 2010 who had at least 1 third molar present and had never undergone
third molar removal. Data were acquired via questionnaire and clinical exami-
nation at baseline, periodic online questionnaires, and clinical examination at 24
months.
Results. A total of 801 patients participated. Among patients undergoing third
molar removal, rates of paresthesia and jaw joint symptoms lasting more than 1
month were 6.3 and 34.3 per 100 person-years, respectively. Among patients not
undergoing removal, corresponding rates were 0.7 and 8.8. Periodontal attach-
ment loss at distal sites of second molars did not significantly differ by third
molar removal status. Incident caries at the distal surfaces of second molars
occurred in fewer than 1% of all sites.
Conclusions. Rates of paresthesia and temporomandibular joint disorder
were higher after third molar removal. Periodontal attachment loss and
incident caries at the distal sites of second molars were not affected by
extraction status. (Am J Public Health. 2014;104:728–734. doi:10.2105/AJPH.
2013.301649)
or TMD, may persist and become chronic or removal, as well as the assessment of conditions
permanent conditions. The overall rate of related to retained third molars during a period
complications from third molar removal varies when they are erupting. Our specific aims
considerably, with values reported from were to compare the rates of paresthesia, TMD,
4.6%10 to 21%.4 Thus, some feel that moni- and caries, as well as periodontal attachment
toring asymptomatic third molars is the ap- loss. A companion article reports on general
propriate strategy.11---13 In fact, the American dentists’ recommendations for retention or
Public Health Association and the United removal of third molars and patient compliance
Kingdom’s National Health Service currently with the recommendations.17
recommend against the removal of asymp-
tomatic third molars.14,15 Nevertheless, about METHODS
50% of insured individuals in the United States
will have their third molars removed by the We conducted a prospective cohort study on
time they are 20.16 third molar removal and retention in the
Many studies have reported on the short- Northwest Practice-based REsearch Collabora-
term complications of third molar removal, but tive in Evidence-based DENTistry (Northwest
few have compared outcomes for patients who PRECEDENT), a dental practice---based re-
do and do not elect to have third molars search network. Network dentists interested in
removed for an intermediate period of time participating in this study underwent formal
(£ 2 years). Therefore, we investigated the enrollment and training. Patients were
sequela of third molar removal or retention recruited from May 2009 through September
over a 2-year period. This time frame allowed 2010 at the offices of participating general
the identification of sequela that were becom- dentists and were followed until April 2012.
ing persistent or chronic after third molar The methods for this clinical portion of the
American Journal of Public Health | April 2014, Vol 104, No. 4

study are described in our companion article.17
Briefly, though, patients aged 16 to 22 years
were invited to participate if they had at least 1
third molar present and had never undergone
third molar removal. We acquired data by
means of a baseline questionnaire and clinical
examination. At 8-month intervals, patients
were asked to complete online questionnaires
describing their third molar status. All patients
who reached at least 18 months of follow-up
time were invited to return for a final clinical
examination (n = 400).
The primary exposure of interest was third
molar removal. The primary outcomes were
TMJ signs and symptoms, paresthesia, caries,
and attachment loss.
The main self-reported outcomes were TMJ
signs and symptoms (jaw clicking and popping,
pain on wide opening, and pain in temples, jaw
joint, or jaw muscles) and paresthesia of the
lower lip, tongue, or both. We performed the
analyses for these outcomes at the patient level.
Patients who had at least one third molar
removed were categorized in the removal
(exposed) group, and patients without any re-
movals were categorized in the retention
group. Because we ascertained removal or
retention status by means of multiple surveys
over the course of follow-up, a patient could
contribute person-years of follow-up to both
the removal and the retention groups. For the
retention group, follow-up started at the base-
line examination and ended at the last
follow-up assessment before report of an ex-
traction (if any). For the removal group,
follow-up started at the first extraction and
ended at the last follow-up. Because all the
self-report outcomes were incident events, we
did not include additional follow-up after a pa-
tient reported an outcome in the respective
analysis. Patients were considered to have
TMD if they reported pain on wide opening or
pain in the temple, jaw joint, or jaw muscles.
The main clinical outcomes were incident
dental caries and change in attachment loss (in
mm/year). Patients who attended the baseline
and final clinical examinations were included in
these analyses. We analyzed these outcomes at
the surface or periodontal site level. A surface
or site was considered to be in the removal
(exposure) group if the adjacent third molar
was extracted during follow-up. The follow-up
time for each surface or site was the time
April 2014, Vol 104, No. 4 | American Journal of Public Health
RESEARCH AND PRACTICE
between the 2 clinical examinations. We de-
fined incident dental caries as a new carious
lesion or restoration on a surface that was
judged as disease free at baseline and calcu-
lated change in attachment loss as the differ-
ence in attachment loss at the distal surfaces of
the second molars between the initial and final
clinical examinations. We evaluated rate of
pericoronitis, as indicated by dentist diagnosis,
as a clinical outcome at the baseline and final
clinical examinations, and it was reported at the
patient level (i.e., any visible third molar with
pericoronitis).
We estimated annual rates, means, and in-
cidence rate ratios (when numbers of events
were sufficient) using log-linear regression
models for TMD signs and symptoms, pares-
thesia, dental caries, and pericoronitis and
a linear regression model for rate of progres-
sion in attachment loss. We used generalized
estimating equations to account for possible
lack of independence between observations
from the same practice. We performed analy-
ses using IBM SPSS Statistics for Windows,
version 19.0.0 (IBM Corporation, Armonk,
NY).
RESULTS
Of 801 participants enrolled at baseline,
517 completed at least 1 follow-up question-
naire, and they were followed for an average of
19.7 months (SD = 5.3). Participants enrolled
at least 18 months (n=400) were invited for
the final clinical examination, of whom 218
(55%) underwent the final examination (Figure
1). The average time between baseline and
follow-up examinations was 21.9 months. The
characteristics of patients who underwent the
final clinical examination did not differ signif-
icantly from the characteristics of the eligible
sample, except for age and frequency of dental
cleanings. Participants who returned for the
final examination were younger (mean age =
17.7 years vs 18.2 years) and had more
frequent dental cleanings (79% vs 59%
reported twice-annual cleanings) than targeted
participants who did not return for final ex-
amination.
At baseline, 49% of the participants were
female, 68% were aged 16 to 18 years, and
90% were White (Table 1). The majority of
patients had private dental insurance (79%),
Huang et al. | Peer Reviewed | Research and Practice | 729
and 65% had routine dental visits at least twice
per year. Of the participants, 30% had at least 1
visible third molar (partially or fully erupted).
Six percent of the participants had dental caries
at the distal surface of the second molars, and
63 participants had dental caries on third
molars (8% of all participants, or 26% of the
participants with visible third molars). Of the
participants, 27% reported clicking or popping
in their TMJ, 13% had jaw pain on wide
opening, and 17% had pain in their temples,
jaw joint, or jaw muscles. The mean attachment
loss at baseline was 0.75 millimeter (Table 1).
Of the 517 participants with follow-up data,
720 third molars were extracted from 201
(39%) participants. They were extracted on
average 7.7 months after study entry (SD = 5.8
months). The majority of participants had all
third molars extracted by an oral surgeon
(73%) in a single visit (97%). Of the partici-
pants, 68% reported that intravenous sedation
or general anesthesia was used, and 30%
reported nitrous oxide was used. Participants
who had at least 1 third molar extracted during
follow-up were more likely to have pain or
discomfort around third molars and periodon-
tal pockets of 4 millimeters or more at the distal
of second molars at baseline (Table 1).
Among the 517 participants with follow-up
data, 316 (61%) retained all existing molars
during follow-up. Among the 218 participants
who returned for the final examination, a gen-
eral trend toward continued eruption of the
third molars was evident (Figure 2). The more
advanced the eruption status was at baseline,
the more likely those teeth were to reach full
eruption in the subsequent 2-year period. At
final clinical examination, 26% of the retained
third molars were partially or fully erupted.
At baseline, 48 participants had 1 or more
teeth diagnosed by the general dentist with
pericoronitis (6% of all participants, or 20% of
the participants with visible third molars). At
final clinical examination, 9 participants had 1
or more teeth diagnosed with pericoronitis (4%
of all participants, or 15% of the participants
with visible third molars). Of 19 third molars
with pericoronitis at baseline that were also
assessed at the final clinical examination, 11
were extracted, and 1 had a second diagnosis of
pericoronitis.
During follow-up, the incidence of self-
reported TMJ clicking or popping was not

812 participants consented
801 baseline questionnaire and clinical
examination
372 8-month questionnaire
371 16-month questionnaire
310 24-month questionnaire
130 Web
180 paper
284 lost to follow-up
517 at least 1 follow-up
questionnaire
FIGURE 1—Study flowchart: Northwest Practice-based REsearch Collaborative in Evidence-
based DENTistry; 2009–2012.
significantly different between participants who
did (11.7 per 100 person-years) and did not
(15.4 per 100 person-years) undergo third
molar removal (Table 2). However, the rates
of TMD (jaw pain on wide opening and pain in
the temples, jaw joint, or jaw muscles) were
significantly higher after third molar removal
(29.0 and 14.0 per 100 person-years, re-
spectively) when compared with those not
undergoing third molar removal (5.5 and
6.3 per 100 person-years). After adjustment
for age and gender, the adjusted incidence
risk ratios for pain on wide opening and
pain in temples, jaw joint, or jaw muscles
indicated 5.2 and 2.2 times higher risks in
patients who underwent third molar removal
than in patients who did not (95% confidence
interval [CI] = 3.3, 8.3 and 1.2, 4.1, respec-
tively; Table 3).
The rates of self-reported paresthesia of the
lip and tongue were also higher in those who
had third molar removal (5.8 and 4.2 per 100
person-years, respectively) than in those who
did not (0.4 and 0.5 per 100 person-years,
respectively). When combined, the rate for
paresthesia during this 2-year follow-up period
was 6.3 per 100 person-years for the removal
730 | Research and Practice | Peer Reviewed | Huang et al.
RESEARCH AND PRACTICE
400 invited for
final clinical examination
182 lost to follow-up
218 final clinical
examination
group and 0.7 per 100 person-years for the
retention group (Table 2).
The rate of incident dental caries on the
distal surfaces of second molars was 0.2 per
100 surface-years for those teeth adjacent to
removed third molars and 0.6 per 100
surface-years for those teeth adjacent to
retained third molars (Table 2). The rate of
incident dental caries on third molars was
3.3 per 100 surface-years for the occlusal
surfaces and 0.2 per 100 surface-years for
non-occlusal surfaces.
The mean changes in attachment loss at
the distal surfaces of the second molars during
the follow-up period were 0.23 millimeter
per year (95% CI = 0.03, 0.43) in sites adja-
cent to retained third molars and 0.12 milli-
meter per year (95% CI = –0.08, 0.32) in sites
adjacent to removed third molars. When
stratified by maxillary or mandibular arch,
the results for attachment loss were essentially
the same. After adjustment for age, gender,
frequency of dental cleanings, and current
smoking, the adjusted mean difference be-
tween the extraction and nonextraction adja-
cent sites was not statistically significant
(0.06; 95% CI = –0.16, 0.28).
American Journal of Public Health | April 2014, Vol 104, No. 4
DISCUSSION
Because third molars are often removed
prophylactically, it can be challenging to
compare the sequela of removal versus
retention over several years. This project was
a natural history study in which patients
were provided with third molar recommen-
dations and then left to choose retention
or removal. As stated previously, our inter-
ests were not in the immediate postsurgical
period, because this interval has been well
documented in the literature. Rather, we
were most interested in medium-term out-
comes, such as dental caries, periodontal
disease progression, paresthesia, and TMJ
symptoms.
Paresthesia has been reported to occur
in about 1% to 5% of patients undergoing
third molar removal. 3,4,18 The rate of pares-
thesia for patients in our study (about 6%)
is not far from the upper bounds of past
reports.
The rate of TMJ symptoms reported by
patients who had undergone third molar
removal was much higher than expected
(> 30% for either joint pain or muscular
pain). The relative risk for TMD (3.8) was
also quite high—more than double that
reported in a prior retrospective study.16
A growing body of evidence has indicated
that third molar removal may result in
TMJ symptoms,16,19,20 and in fact the 2012
American Association of Oral and Maxillofacial
Surgeons’8 Parameters of Care state that third
molar removal may cause or exacerbate TMJ
symptoms.
Many articles have stressed the importance
of prophylactic removal of third molars to
prevent periodontal pathology and the poten-
tial systemic health problems associated with
periodontal disease.7,9,21---23 However, much
of this research has been conducted by 1 group
of investigators using 4-millimeter or deeper
pockets as indicative of periodontal pathology.
Obviously, a 4-millimeter pocket in the second
and third molar area may be influenced by
the eruption status of the third molar, and it
is unclear whether a 4-millimeter pocket is
always indicative of periodontal disease, which
is usually based on attachment loss and the
presence of inflammation rather than just
 RESEARCH AND PRACTICE

pocket depth.24 Additionally, some recent

TABLE 1—Baseline Characteristics of the Participants by Removal Status at Follow-Up: publications have not indicated a causal re-
Northwest Practice-based REsearch Collaborative in Evidence-based DENTistry, Pacific lationship between periodontal disease and
Northwest, 2009–2012 systemic health.25,26
Third Molar Removal Status at Follow-Up,a % or Mean (SD) Although attachment loss, rather than
pocket depth, was the primary periodontal
Total (n = 801), Third Molar Removal Third Molar Retention
Characteristic % or Mean (SD) (‡ 1; n = 201) (All Existing; n = 316) outcome in our study, we conducted a post hoc
analysis of pocket depth change to allow for
Gender comparison with a prior study.27 We found
Female 49 51 51 that fewer than 3% of all second molar distal
Male 51 49 49 sites with 4 millimeters or more pocket depth
Age, y at baseline had increases in pocket depth of
16 24 28 23 2 millimeters or more during the follow-up
17 23 23 20 period, regardless of third molar removal. This
18 21 20 21 previous study reported that 38% of second
19 12 12 13 molar distal sites with 4 millimeters or more
20 9 7 11 pocket depth at baseline had increases in
21–22 11 9 13 pocket depth of 2 millimeters or more during
Raceb the follow-up period of 2.2 years.27 These
White 90 92 91 rates are considerably higher than what we
Other 8 7 8 observed in our study. However, it is difficult
Dental insurance to directly compare our study with this pre-
No insurance 10 12 9 vious study because their patients were on
Medicaid 11 6 7 average 7 years older, with most third molars
Private insurance 79 82 84 partially or fully erupted.
Frequency of dental cleanings At the patient level, 1 in 5 participants with
‡ 2/y 65 72 67 visible third molars at baseline had evidence
1/y 23 22 23 of pericoronitis. The low occurrence of re-
< 1/y 12 7 9 peated diagnosis of pericoronitis at baseline
Current smoking and follow-up might suggest that spontaneous
No 94 95 97 resolution is common. However, another
Yes 6 6 3 possibility is that teeth with pericoronitis might
Eruption status of third molars be preferentially removed, thus masking
None visible in mouth 70 72 70 a higher rate of recurrence. Our results from
‡ 1 visible 30 29 30 a companion article are consistent with this
Angulation (highest in patient) theory.17
£ 35˚ 51 45 53 The incidence of caries on the distal
> 35˚ 49 55 47 surfaces of second molars was extremely low,
Pain or discomfort around third molarsc whether third molars were removed or
No 85 82 90 retained. In the patients who returned for
Yes 15 19 10 a 2-year follow-up examination, fewer than
Dental caries at distal of second molar 0.5% of surfaces displayed evidence of in-
No 94 96 96 cident caries overall. It is possible that this low
Yes 6 4 4 rate of new lesions was related to the low
Dental caries on third molars rate of prevalent decay noted at baseline. Only
No 92 94 92 6% of our patients exhibited evidence of
Yes 8 6 8 decay at distal of second molars at enrollment.
Paresthesia This rate compares with rates as high as
No 99.6 99 99.7 13% to 20% in other studies.28,29 The pro-
Yes 0.4 1 0.3 portion of patients with decay or restoration
Continued in at least 1 third molar at baseline was 8%,
which compares with a previous study report-
ing that 9% of third molars in participants

April 2014, Vol 104, No. 4 | American Journal of Public Health Huang et al. | Peer Reviewed | Research and Practice | 731
 RESEARCH AND PRACTICE

On average, third molars that were not

TABLE 1—Continued extracted displayed continued eruption over
Pericoronitis the 2-year period. In fact, we found it surprising
No 94 94 95 that 50% of all third molars that were classified
Yes 6 7 5 as partially erupted at the time of enrollment
TMD signs and symptoms (categories were classified as fully erupted at the end of the
not exclusive) study. Even 18% of teeth classified as soft
None 64 63 62 tissue impactions at baseline were considered
Popping or clicking 27 27 29 fully erupted 2 years later. This information is
Jaw pain on wide opening 13 13 9 generally in line with research conducted by
Pain in temples, jaw joint, or 17 20 16 Venta et al.,31 who reported on eruption for
jaw muscles patients in their early 20s. Obviously, the
Maximum pocket depth at distal of favorable rates of eruption observed in this
second molarc study may be affected by the possibility that
< 4 mm 41 31 50 teeth with poor eruption potential were pref-
‡ 4 mm 59 69 50 erentially targeted for removal. This issue
Attachment loss at distal of 0.75 (1.09) 0.82 (1.11) 0.57 (0.90) highlights 1 major limitation of observational
second molar, mm studies: the potential for confounding by
indication.
Note. TMD = temporomandibular joint disorder. This study also had other limitations. Pa-
a
284 participants were lost to follow-up, and third molar removal status is unknown.
b
14 participants did not report race. tients were obviously influenced by the rec-
c
P < .05 between removal and retention group from bivariate generalized estimating equations logistic regression. ommendations of their dentists, most of whom
indicated that they favored third molar re-
moval for prophylactic reasons. Regardless of
younger than 25 years had caries.30 In the challenging, occlusal surfaces are usually the their dentists’ recommendations, patients were
present study, almost all incident caries ob- most accessible to dentists. Sealants may be allowed to self-select whether they would or
served on third molars was on the occlusal beneficial if these teeth are being considered would not undergo third molar removal, and
surface. Although restoring third molars can be for retention. certainly many factors, such as availability of
insurance coverage and patient symptoms,
influenced the decision. It is likely that this
17 Fully erupted
self-selection resulted in nonequivalence of the
Partially erupted 17 Partially erupted
extraction and nonextraction groups for vari-
(n = 69) 0 Unerupted (tooth not visible
clinically)
ous potentially confounding factors, many of
35
Extracted which would be difficult to address. However,
Eruption Status at Baseline

15 randomizing patients to retain or remove

Soft tissue impaction 27 third molars prophylactically could present
(n = 166) 42 a patient acceptance challenge. Another limi-
82 tation was the 2-year follow-up period. It would
be desirable to follow these patients for longer
2
than 2 years, perhaps for as long as a decade
Partial bony impaction 21
until patients neared their 30s. The response
(n = 264) 133
rate for the questionnaires, which ranged from
108
40% to 50% for the 3 time points, was lower
0 than anticipated, even though we offered in-
Complete bony impaction 5 centives and facilitated access to questionnaires
(n = 212) 117 with embedded links in e-mails. Perhaps the
90 low rates should not be unexpected given the
age of our patients and the fact that many
Eruption Status at Follow-Up
transitioned into college or the workforce
FIGURE 2—Change between baseline and study end in eruption status of third molars not during the 2-year follow-up period. We also
fully erupted at baseline: Northwest Practice-based REsearch Collaborative in Evidence- fell short of our target of 300 participants
based DENTistry, Pacific Northwest, 2009–2012. for the 24-month follow-up examinations.
One positive factor is that the characteristics

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 RESEARCH AND PRACTICE

TABLE 2—Outcomes of Third Molar Removal or Retention: Northwest Practice-based Research Collaborative in Evidence-based DENTistry,
Pacific Northwest, 2009–2012

Third Molar Removal Third Molar Retention

Total, Rate per 100 Total, Rate per 100
Variable No. Cases Person-Years Person-Years (95% CI) No. Cases Person-Years Person-Years (95% CI)

TMD
Jaw clicking or popping 16 137 11.7 (7.2, 19.0) 56 363 15.4 (12.3, 19.4)
Jaw pain on opening 38 131 29.0 (20.5, 41.1) 24 435 5.5 (3.8, 7.9)
Pain in temples, jaw joint, or jaw muscles 19 135 14.0 (8.2, 23.9) 27 431 6.3 (4.1, 9.6)
Either type of TMD pain symptoms 43 126 34.3 (24.0, 48.9) 38 431 8.8 (6.4, 12.2)
Paresthesia
Paresthesia of lips 11 190 5.8 (3.0, 11.3) 2 549 0.4 (0.1, 1.4)
Paresthesia of tongue 8 191 4.2 (1.9, 9.1) 3 546 0.5 (0.2, 1.7)
Paresthesia of lips, tongue, or both 12 190 6.3 (3.4, 11.8) 4 548 0.7 (0.3, 1.9)
Dental cariesa
Dental caries at distal of second molars 1 528 0.2 (0.0, 1.4) 4 678 0.6 (0.2, 1.5)
Dental caries at occlusal of third molars NA 9 275 3.3 (1.6, 6.8)
Dental caries at all other surfaces of third molars NA 3 1226 0.2 (0.1, 1.1)
Dental caries on third molars, overall NA 12 1501 0.8 (0.4, 1.7)

Note. CI = confidence interval; NA = not applicable; TMD = temporomandibular joint disorder.

a
Dental caries are reported in surface-years

of patients who did return questionnaires and to cite a recent systematic review that was adults” is insufficient.32(p2) This systematic
did undergo the final examination were rela- conducted under the auspices of the Cochrane review highlights the need for better research
tively similar to the characteristics of the entire Collaboration.32 This systematic review inves- on the topic of third molars.
sample at baseline. Strengths of this study are the tigated randomized clinical trials on surgical Surely, some third molars, perhaps many
multisite structure of the network, which im- removal versus retention for the management third molars, should be removed because of
proves generalizability to broader populations. of asymptomatic third molars. After an ex- insufficient space, poor eruption paths, recur-
The debate on third molar management tensive search, Mettes et al. identified only 1 rent pericoronitis, periodontal disease, or other
has existed for many decades. A PubMed trial that met their inclusion criteria, and the pathology. However, it also seems likely that
search conducted in January 2013 using the only outcome reported in that trial was that in some individuals, third molars might have
term “third molar” resulted in more than third molar removal or retention did not sufficient space and exist for a lifetime as
7000 articles, and restricting the search to appear to be associated with lower incisor healthy, functional teeth. Our charge, as den-
systematic reviews still netted almost 100 crowding. Their conclusion was that the evi- tists, is to thoroughly assess a patient’s unique
references. With all this literature available dence to “support or refute routine removal circumstances, to educate our patients on
in peer-reviewed journals, it is interesting of asymptomatic impacted wisdom teeth in their condition, to utilize the existing evidence,
and to provide our best advice and care for
the management of their particular oral condition.
Third-molar decisions should be no different.
TABLE 3—Association of Third Molar Removal Status and TMD: Northwest Practice-based In summary, our study provides informa-
REsearch Collaborative in Evidence-based DENTistry; Pacific Northwest; 2009–2012 tion on a 2-year observation period of pa-
TMD Symptoms Adjusted Incidence Rate Ratioa (95% CI) P tients in their late teens and early 20s when
decisions are often made regarding third
Jaw clicking or popping 0.8 (0.4, 1.3) .32 molar removal. The network setting allowed
Jaw pain on wide opening 5.2 (3.3, 8.3) < .001 the recruitment of a large number of
Pain in temples, jaw joint, or jaw muscles 2.2 (1.2, 4.1) .014 participants, and we were able to investigate
Either type of TMD pain symptoms 3.8 (2.5, 5.7) < .001 conditions related to both retention and
Note. CI = confidence interval; TMD = temporomandibular joint disorder. removal. We report the following conclu-
a
Adjusted for age and gender. sions in a population of patients, 79% of
whom were covered by dental insurance.

April 2014, Vol 104, No. 4 | American Journal of Public Health Huang et al. | Peer Reviewed | Research and Practice | 733

1. The rates of paresthesia and TMD
symptoms were significantly higher
in patients who underwent third molar
removal, and these effects lasted
longer than the immediate postsurgical
period.
2. The average rate of attachment loss at
distal sites of second molars was minimal
over a 2-year period, regardless of third
molar retention or removal.
3. The incidence of caries on the distal surface
of the second molars was less than 1%.
For third molars, the caries rate was ap-
proximately 3.3% on the occlusal surfaces.
4. When third molars were not removed,
considerable eruption occurred during
the 2-year period. j
About the Authors
Greg J. Huang is with the Department of Orthodontics,
Joana Cunha-Cruz and Charles Spiekerman are with the
Department of Oral Health Sciences, Marilynn Rothen is
with Regional Clinical Dental Research Center, and Mark
Drangsholt is with the Department of Oral Medicine, School
of Dentistry, University of Washington, Seattle. Loren
Anderson is in private practice, Kennewick, WA. Gayle A.
Roset is in private practice, Billings, MT.
Correspondence should be sent to Greg J. Huang, De-
partment of Orthodontics, Box 357446, University of
Washington School of Dentistry, 1959 NE Pacific Street,
Seattle, WA 98195-7446 (e-mail:ghuang@uw.edu).
Reprints can be ordered at http://www.ajph.org by clicking
the “Reprints” link.
This article was accepted August 22, 2013.
Contributors
G. J. Huang conceptualized the study, developed the
protocol with the study team, supervised the conduct of
the study, interpreted the data, and wrote the first draft of
the article. J. Cunha-Cruz developed the protocol and
clinical research forms with the study team, assisted in
study supervision and conduct, interpreted the data,
and assisted with article preparation. M. Rothen was the
lead regional coordinator for Northwest Practice-based
REsearch Collaborative in Evidence-based DENTistry
(PRECEDENT) and assisted in study supervision and
conduct, as well as article preparation. C. Spiekerman
conducted the data analysis and assisted with article
preparation. M. Drangsholt assisted in developing the
protocol and with article preparation. L. Anderson and
G. A. Roset collected data and assisted with article
preparation.
Acknowledgments
This article was submitted on behalf of the Northwest
PRECEDENT network, with support from the National
Institute of Dental and Craniofacial Research
(DE016750 and DE016752), National Institutes of
Health, Bethesda, MD.
We thank the dentist-investigator members of North-
west PRECEDENT and their staff for their invaluable
contributions.
734 | Research and Practice | Peer Reviewed | Huang et al.
RESEARCH AND PRACTICE
Human Participant Protection
The institutional review board at the University of
Washington reviewed and approved the study protocol.
All participants provided informed consent.
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